Spring systems

In this set-up, the system mainly uses a spring. The spring is used to measure the torque strength on the spindle. The springs in this system are always marked and calibrated to make it easy to note and read the measurements. Usually, about three to four spring ranges exist. Of importance to note here is that, each particular range is directly related to a particular strength of viscosity. To take care of the normal range of viscosity, around three or four instruments are needed.

The spring viscometer set-up is mainly founded on a concept mainly from the pivot and spring principle. A pivot and spring connection is made to rotate around the shaft. The spindle is also usually connected to this set-up. The working is usually such that, when the spindle rotates in a circular manner, the friction of the fluid on the spindle forces the spring to move. It is normally referred to as deflection. The deflection caused has a direct relationship with the torque as a result of the torque of the viscosity of the fluid. It is possible to automatically determine this relationship between the torque deflection and the viscosity.

This spring system has an advantage in that it offers measurements of very high accuracy, the accuracy is more observed in fluids with much lower viscosity ranges. Although this is an advantageous feature of the spring system, it has a major dis-advantage in that it can only measure a limited and regulated range. Measuring range of each of the spring and pivot set-up is limited. This means that there are some levels, especially if the fluid is too viscous that the spring system cannot produce accurate results as might be desired.

The spring system is a delicate set-up, founded on a spring system. A lot of care should be put in place to protect it from getting any damage that might interfere with its proper working. The system should be regularly checked to make sure it is in proper working conditions. An improperly maintained spring system is likely to give un-correct results.

The markings and the calibrations particularly must be inspected regularly and always adjusted to make sure they read the correct numbers.

Servo Systems

Servo system is the second system that can be used to measure the torque. This system mostly relies on a servo motor. The precision servo motor is used to move the shaft. In this system, the spindle is usually connected directly to the shaft. This is unlike in the spring system in which the spindle is connected to the pivot.

It is important to determine the amount of current needed to move the shaft. The determination of the amount of current is usually done by the use of a device known as the servo encoder. This device works by determining the speed in which the system rotates. Also, a gadget known as a micro-processor is usually used. The micro-processor usually works by finding and calculating the amount of current required to move the servo at the usually set speed. When the spindle moves in a rotational manner, the frictional force or drag of the fluid acting on the spindle, causes the system to need and use more current so that it can be able to maintain the spindle moving at the initial speed that is usually set by the user to fit the required need.

To get the total torque, usually take the current as indirectly proportional to the torque. Viscosity on the other hand is taken as to be directly proportional to the total amount of current produced. By a simple calculation therefore, it is possible to determine both the viscosity and the torque of a given sample of a fluid.

By a little consideration, it is possible to realize that servo system is more advantageous than the spring system in a given number of ways. First, servo system offers a very wide of measuring viscosity in a particular instrument. Some of these ranges could for example be from 2cps to around 90 million cps. This means that, the servo system is not as limited as the spring system and hence can serve a wide range of purpose as its need might arise.

Another important advantage of the servo systems to note is that, it offers much great ranges for the measurement of torque and speed. Another very important factor to note about the servo system is that, this set up, unlike the spring set up which require frequent and constant re-checking of the calibrations and markings, the servo system can actually stay for a very long time without requiring re-marking and re-checking.

The main disadvantage of the servo system is that; more friction is experienced in this set up than in the spring set up. This means that the accuracy, especially in low speeds is highly reduced and also the accuracy for low viscosity is less than that of the spring set up.

What is the background? Describe what happened in the project
Even by the most conservative prevalence estimates, about 50 million people are affected by mental health problems in India. In contrast to this high burden, the country has approximately 5000 mental health professionals. It is clear that mental health care needs to be radically rethought if the country is likely to meet more than a tiny fraction of the needs of people affected by mental health problems. It is in this context that Sangath, an Indian NGO, began shaping its approach to using lay people to deliver evidence based psychosocial interventions for mental health problems. Inspired by similar approaches to ‘task-sharing’ interventions in other areas of health care in India, such as maternal and child health, Sangath adopted an approach which was replicated across a diverse range of mental health conditions. This approach is characterised by several principles: designing interventions based on global evidence of effectiveness and local evidence of cultural acceptability; systematically testing intervention delivery to ensure feasibility of its delivery by lay health workers and acceptability by patients and families; involving diverse stakeholders, in particular people affected by the target mental health problems, in shaping the content and delivery of the intervention; embedding the intervention in established health care platforms, most commonly those run by the government, to ensure scalability; evaluating the effectiveness and cost-effectiveness of the intervention in randomized controlled trials; disseminating the findings in a variety of methods, ranging from scientific papers to audio-video media; and working closely with federal and state ministries of health to scale up the innovations.

Several lessons emerged from these experiences, which have been coined into the acronym “SUNDAR” (which means ‘attractive’ in the Hindi language).

First, that we should Simplify the messages we use to convey mental health issues, for example avoiding using psychiatric labels which can cause shame or misunderstanding.
Second, that we should Unpack our interventions into components which are easier to deliver and incorporate culturally sensitive strategies.
Third, that these unpacked interventions should be Delivered as close as possible to people’s homes which typically translates to their actual homes, or the nearest primary health care centre or community facility.
Fourth, that we should recruit and train Available manpower from the local communities to deliver these interventions. This often refers to lay health workers, but could also include parents and teachers in the case of childhood disorders.
And finally, that we should judiciously Reallocate the scarce and expensive resource of mental health professionals to supervise and support these community health agents.
This approach is built around a collaborative care framework with four key human resources: the front-line lay health worker; the person with a mental health problem and his/her family; the primary or general health care physician; and the mental health professional. SUNDAR is attractive because it is improves access to care using available human resources in an efficient way and because it empowers ordinary people to provide mental health care for others-and, in so doing, promotes their own well-being. There are a number of NGOs in the developing world which are working to build skills in community based workers to deliver psychosocial treatments for mental health problems, but few who are using scientific methods to evaluate the effect of these approaches and working closely with ministries of health to take these innovations to scale. Sangath stands out as a rare example of an innovator committed to community empowerment, science and scaling up in low resource settings.

What was the impact and what can be learned?
We have completed randomized controlled trials of the SUNDAR approach for three conditions (dementia, schizophrenia, common mental disorders) and all have shown significant benefits on clinical and social outcomes. The dementia trial (“the Home Care Trial”) was the first such study from a developing country and won Alzheimer Disease International’s international prize for psychosocial interventions in 2010. The common mental disorders trial (the “MANAS” trial) was the largest trial in psychiatry from the developing world and the first to demonstrate the cost-effectiveness of task-sharing for mental health care. Results of our trials for alcohol use disorders, maternal depression, mental health in young people and autism will become available in the near future. This evidence has been used to scale up mental health care in rural communities in one of the poorest regions of the country through VISHRAM (Vidarbha Stress and Health Program), a partnership between Sangath, social development NGOs, the Ministry of Health and psychiatrists. Excitingly, the new National Mental Health Program of the Ministry of Health (Government of India) which finances the District Mental Health Program has, based on this evidence, mandated for the establishment of a new cadre of community mental health worker attached to primary health care centres throughout this vast country. This promising evidence has also led to a revolution in the field of global mental health research with task-sharing amongst the leading research priorities in the Grand Challenges for Global Mental Health which has leveraged more than 50MUS$ in the past two years to support more research and capacity building in this area. As a beneficiary of some of this new research funding, we have begun to experiment with the use of peers to deliver interventions, such as using mothers to deliver evidence based psychological treatments for depressed mothers in their community and the use of mHealth to empower parents of children with neurodevelopmental disabilities. What is truly SUNDAR about this innovation of task-sharing is its potential significance for developed countries. While it would come as no surprise to learn that there are astonishingly large gaps in access to evidence based care in developing countries, the real puzzle is that despite the apparent richness of resources, large proportions of people do not access such care even in developed countries. There are many explanations for this observation, at the heart of them all is the remoteness of mental health care from the communities it serves: the interventions are heavily medicalized, do not engage sufficiently with harnessing personal and community resources, are delivered in highly specialized and expensive settings, and use language and concepts which alienate ordinary people. In all these respects, the SUNDAR approach might be instructive to rethinking mental health care globally. At the core of this innovation is revisiting the questions of what constitutes mental health care, who provides mental health care and where mental health care is provided. By using appropriately trained and supervised lay workers, working in settings and at times convenient to the patient (even in their homes and outside regular working hours), offering a range of contextually appropriate interventions tailored to the needs of the individual and using familiar labels and concepts, SUNDAR is an approach with great relevance to rethinking mental health care in all countries. By acting on the axiom that mental health is too important to be left to mental health professionals alone, SUNDAR seeks to achieve a paradigm shift by reframing so called ‘under-resourced’ societies to being ‘richly-resourced’ for there is surely no society on earth which is not richly endowed with human beings who are capable of caring for those with mental health problems.

With one thousand days to achieve the Millennium Development Goals, low-income countries are redoubling their efforts to reach their most vulnerable citizens. In the process, communities have been recognized as being central to achieving the goals of universal primary care. This deep relationship has come through the hard work of building linkages between households and health facilities through Community Health Workers (CHW). The basic principle of supporting full-time, paid CHWs in communities is taking root in the United States in the context of health care reform, and forms basis for a global exchange.

Across 10 countries in Sub-Saharan Africa in the Millennium Villages Project, a CHW plays a decisive role in reducing child mortality and supporting maternal health. In the example of malaria, CHWs work in the following manner: when a child has a fever, a CHW is alerted in one of three ways: (1) the mobile phone-enabled emergency response system; (2) symptom recognition during a regular household visit; or (3) a community member request for the CHW’s presence based on acute symptoms. Upon arrival in the household, the CHW quickly administers a rapid diagnostic test (RDT) for malaria, part of the standard CHW supply kit, to the child with the fever. If the test is positive, the CHW uses a mobile phone to record the encounter, register the results, receive confirmation on dosage, and alert the primary health care system to support follow up. The CHW then provides the requisite treatment dose of Coartem (or other first-line medicine) on the spot, ideally around thirty minutes after arrival onsite.

At large scale in Sub-Saharan Africa, the CHW has the power to contribute to the achievement of the MDGs for a handful of targeted conditions as described for malaria above. We have launched the One Million CHW Campaign  to ensure that the evidence-based impact of a CHW is available across rural areas where poverty and disease burden is greatest. A recent report commissioned by the Gates Foundation concluded that 3.6 million child deaths could be averted if coverage was expanded to the countries with the highest burden of child mortality. Talking seriously about this degree of scale-up is possible through the intense focus on scalable supervision, rapid training through mobile learning platforms, real-time monitoring of progress and innovations in communications between the community settings and clinic. Although the condition focus is significantly different in the US, the basic systems and unique ambassadorial function of a CHW remains the same.

Taking the learning to Harlem

The Earth Institute is the founding technical advisor for City Health Works  a social enterprise based in Harlem, New York City, which is building a financially sustainable CHW system for the US. A Robert Wood Johnson funded study estimates that 30 percent of health is shaped by health behaviors and 40 percent by social and economic factors, while only 20 percent by clinical care. Yet, clinics and hospitals are not optimized to monitor and improve behavioral and social determinants of health in the neighborhoods they serve. The US health system lacks a dedicated, interdependent platform to support primary prevention and long-term behavior change in community settings. The need for a scalable system to cost-effectively reach low resource communities outside of clinic and hospital settings is becoming particularly urgent as Accountable Care Organizations and Medical Homes take form. These institutions will now be held financially accountable for patient populations’ health outcomes. Cost and quality pressures are mounting as the medical burden of obesity accounts for $168 million dollars a year (16.5% of health spending). Rates of obesity-related chronic conditions across the United States have increased rapidly over the last 30 years, with 79 million Americans pre-diabetic, 26 diabetic and one out of three American adults having high blood pressure. Further, individuals with chronic conditions have double the rate of depression relative to healthy individuals.

In a setting like Harlem, the CHW has three major functions, which include 1) early risk detection, 2) chronic condition self-management coaching for individuals and groups and 3) coordination of care with primary health care systems. Unlike facility based medical personnel, the CHW works in the community where they live and can develop a culturally matched, long-term relationship with the people they serve. Furthermore, they are well positioned to be advocates for social determinants of health such as improved housing conditions and increasing the availability of nutritious food choices. The goal of our work with City Health Works is to develop the right balance of financial support from insurers, hospital systems, and healthy local businesses to sustain a paid network of CHWs. As this work evolves, the most essential lessons we have learned through the Millennium Villages Project and One Million CHW Campaign augment the decades of experience by US-based groups.

We anticipate that in time, it will be natural to see exchanges between CHWs with health systems as different as Brazil, Nigeria, United States and India’s. The fundamental relationship between community and health systems is foundational to achieving universal primary health care, and CHWs are in the best position to help the world reach this goal.

Authors

Jeffrey D. Sachs is a world-renowned professor of economics, leader in sustainable development, senior UN advisor, bestselling author, and syndicated columnist. Professor Sachs serves as the Director of The Earth Institute, Quetelet Professor of Sustainable Development, and Professor of Health Policy and Management at Columbia University. He is Special Advisor to United Nations Secretary-General Ban Ki-moon on the Millennium Development Goals, having held the same position under former UN Secretary-General Kofi Annan. He is Director of the UN Sustainable Development Solutions Network.

Prabhjot Singh is the Director of Systems Design at the Earth Institute and Assistant Professor of International and Public Affairs at Columbia University. He is the co-chair of the One Million Community Health Worker Campaign, which is an initiative of the African Union and UN Sustainable Development Solutions Network. Domestically, he focuses on developing community-based health care delivery systems, where he is a practicing doctor in East Harlem.

What is the background? Describe what happened in the project
Clubfoot is a congenital condition that occurs in approximately one in every 5/600 births in sub-Saharan Africa. If not treated it deteriorates as the child starts to walk and results in a severe deformity as seen here in a teenager from Cambodia. In developed countries where surgery was available, most children had access to satisfactory treatment. In resource poor countries where there were few surgeons it was a different matter and many children ended up with severe deformity that stopped them from going to school or getting paid employment. Fortunately a new and very effective non surgical treatment involving intensive manipulation and minor tendon release surgery was developed in Iowa USA by professor Ignatio Ponseti, and published in the late 1990s. It was slow to take off in the USA and Europe as the establishment is always slow to change, and surgery was readily available. In Uganda and Malawi however the new technique was adopted eagerly, as there were so few surgeons and so many children needing treatment. Thanks to the Uganda Sustainable Clubfoot Project and the Malawi National Clubfoot Project these 2 countries became the first 2 countries in the world to have a national clubfoot programme where efforts were made to offer treatment to every child who needed it.

What was the impact and what can be learned?
We learned that by involving the Ministry of Health, and all the major stakeholders in physical impairment we could set up national clubfoot treatment programmes in Uganda and Malawl. We also learned and showed that the treatment given by locally trained paramedic clinical officers was as good as that given by postgraduate surgeons and physiotherapists. [1] From Malawi and Uganda teams were invited to other African countries in the region, and also to West Africa to help set up national programmes. A team from Malawi also went to Cambodia to help start their programme and share what they had learned. UK doctors went to Malawi to learn the technique of effective manipulation in the early 2000s as there was so much more experience there than could be had in the UK. One UK doctor Steve Mannion went to Malawi and learned the technique then brought it back to several hospitals in England, earning the plaudit of being one of Lord Robert Winston’s “BBC superdocs”. We also modified and improved Ponsetis technique in Malawi by showing that gaps between manipulation did not need to be the standard Western one week, but could be reduced to as little as two days without affecting the efficacy of the treatment. This finding from Malawi was published in one of the worlds leading peer reviewed children’s surgery journals and has the potential to dramatically reduce treatment times from 6 weeks to 2 weeks

The Centre for Global Mental Health (CGMH) is a partnership between the London School of Hygiene and Tropical Medicine (LSHTM) and King’s Health Partners (KHP). The CGMH was launched in October 2009 with the aim of furthering the emerging field of global mental health. The vision of the CGMH is foster research and capacity building in policy, prevention, treatment and care with the ultimate objective of closing the treatment gap for people living with mental, neurological and substance use disorders. While access to affordable, effective treatment is a problem in all world regions, the focus of the CGMH’s work is in poorer countries, where health systems are greatly under-resourced, and populations particularly under-served.

CGMH are delighted to be collaborating with TTWUD Mental Health Challenge, as a fantastic opportunity to highlight the great work being done in low and middle income countries, and to encourage the spread of innovations that will improve the lives of people suffering from mental health problems.

Submit a case study to share your work and have the chance to pitch your idea to our high profile panel and win the Turning the World Upside Down – Mental Health Award. The goal of the challenge is to collect, promote and celebrate alternative approaches to mental health from low and middle income countries.

Turning the World Upside Down – Mental Health Award is a collaboration with the Centre for Global Mental Health, Institute for Healthcare Improvement, Maudsley International, Mind, and NYU’s Program in Global Mental Health
Why mental health?

Mental health conditions are the greatest contributor to years of life lost to disability worldwide. They worsen the course of most medical conditions and stand in the way of our key drivers for social improvement. As mental health seems to be finally taking its place on the global health agenda, attention is growing on the inability of mental health systems and policies to live up to this challenge. Services can be fragmented, policy siloed, access to care poor, preventive and population-level strategies underused, evidence-based interventions variably deployed, healthcare not culturally relevant, and investment limited.

Both high and low-income countries face these challenges. Countries with fewer resources, and without the baggage and vested interests found in high income countries, often cultivate their own unique climate for innovation and finding practical solutions.

By changing the flow of information we can turn the global mental health world upside down, driving new and needed change, and offering perspectives and solutions to these same challenges in high-income countries.

Join the movement

We want to celebrate your work and to do this, we need you. We are searching for projects, practices, and ideas from low and middle income countries with global relevance that we can learn from in high income countries and the rest of the world.

Do you want the opportunity to present your work to Lord Nigel Crisp, Peter Piot and a high profile panel in an event live streamed around the world? Do you want to be the winner of our Turning the World Upside Down Mental Health Award?

To enter all you need to do is register and submit a case study by midnight on the 31st of October. By the 12th of November we will have shortlisted 6 entries who will be invited to present at the Turning the World Upside Down Mental Health Award Event on the 27th of November.

Entries will be continually displayed and showcased mentalhealth throughout the competition.

The challenge is open to all: patients, health workers, researchers, policy makers, managers. It doesn’t matter what you’re background is, as long as you have an idea to share. Please spread this challenge far and wide; with friends, colleagues and across your networks. We want to reach anyone who could help in making mental health better worldwide.

What are we aiming to achieve?

We hope this challenge will stimulate a huge range of entries to showcase the incredible work going on to improve mental health around the world. By sharing and celebrating case studies, we can aid the global adoption and upscaling of positive practices and ideas.

The challenge underscores the equal footing and common ground that needs to be purposefully pursued in the development of global approaches to mental health.

What are we looking for?

We’re looking for entries that highlight projects, practices and ideas from all sectors and professional groups. We believe that good city-planning is just as essential to mental health as emergency psychiatric care, and we hope that your entries reflect this. Here are a few questions that show the scope of entries that we will accept:

How can we leverage social and community networks? How can we better integrate mental health into wider health and social goals? How can online technology and mobile networks be utilised to improve mental health and manage care? How can we better involve patients in decision-making? What are the possibile benefits of public-private partnerships? Can we better share tasks between health professionals to integrate and expand care?

We want you to provide the answers to these questions and more, by sharing your experience, your work and your ideas.

We hope your answers will stimulate a much-needed rethink on strategies and practices for mental health around the world.

The Platform

Turning the World Upside Down  is designed to identify, promote and celebrate learning and ideas relevant to health from people living and working in low and middle income countries. At the core of the platform is the belief that knowledge transfer and innovation is two way. It is particularly focused on what high income countries can learn from low and middle income countries.

The site is an open and inclusive online platform, where anyone can share and contribute their experiences, ideas and insights by submitting a case study, writing a commentary on those already there, or commenting on and sharing individual case studies.

The case studies are examples where people have developed new ideas or new skills or are using old insights and practices which could be – or have been – transferred to other countries. The case studies will form a reservoir of ideas and inspiration both for research and practical action.

Prominent figures in global health such as Nigel Crisp, Paul Farmer, Srinath Reddy, Sally Davies, Don Berwick, Julio Frenk, Maureen Bisognano, Francis Omaswa, Bruce Keogh and Peter Piot and more have agreed to review the case studies and publish a commentary both on individual cases and the trends they identify.

We received 34 high quality case studies from across the world, 4 of which were presented and discussed at our high-level event in London in November. You can watch a video recording of the event below, or read the case studies submitted to the challenge including our winner, the Dream-A-World cultural therapy